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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (Page s of 6) XII . LINE LEAK DETECTOR TESTING ❑ Check this box if line leak detectors (LLD) are NOT installed . (Do not complete this section.) Y N NA This section must be completed if LLDs are installed. Was a leak simulated to verify LLD performance? 0 ❑ E (Check all that apply.) Simulated leak rate verified : ❑X 3 GPH ❑ 0. 1 GPH ❑ 0 .2 GPH Was the testing apparatus properly calibrated ? ❑X ❑ ❑ For emergency generator tank systems , does the LLD create an audible and visual alarm when a leak is detected ? ❑ ❑ X❑ For mechanical LLDs , does the LLD restrict the flow through the pipe when a leak is detected? ❑X ❑ ❑ For electronic LLDs , does the turbine automatically shut off when a leak is detected? ❑ ❑ ❑X For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected ? ❑ ❑ X❑ For electronic LLDs , does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? ❑ ❑ XQ For electronic LLDs , have all accessible wiring connections been visually inspected for kinks and breaks ? ❑ ❑ NWere all items on the equipment manufacturer's maintenance checklist completed ? X ❑ ❑ Were all LLDs confirmed operational within regulatory requirements? ❑X ❑ ❑ For any answer of "N" above, describe in Section Xlll how and when these issues were or will be corrected. XIII . COMMENTS XIV. VACUUM / PRESSURE / HYDROSTATIC MONITORING EQUIPMENT TESTING ❑ Check this box if VPH monitoring is NOT used . (Do not complete this section.) This section must be completed if VPH monitoring is used to perform leak detection monitoring. System Type (Mark all that apply. ) ❑X Vacuum ❑ Pressure ❑ Hydrostatic Sensor ID Component(S) Monitored By This Sensor Sensor Functionality Interstitial Communication Test Test S 1 87 PRODUCT ❑X Pass ❑ Fail ❑X Pass ❑ Fail S2 VENT 87 QX Pass ❑ Fail OX Pass ❑ Fail S3 87 VAPOR QX Pass ❑ Fail QX Pass ❑ Fail S4 91 PRODUCT ❑ Pass QX Fail ❑X Pass ❑ Fail S5 91 VENT ❑X Pass ❑ Fail QX Pass ❑ Fail S6 DIESEL PRODUCT ❑X Pass ❑ Fail ❑X Pass ❑ Fail S7 DIESEL VENT OX Pass ❑ Fail ❑X Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail How was interstitial communication verified? QX Simulated Leak at Far Ends of the Interstitial Space ❑X Visual Inspection ❑ Other (Describe the method in section XV below.) ❑X Gauge Was the vacuum or pressure restored to operating levels in all interstitial spaces? ❑X Yes ❑ No (Describe the reason in section XV below.) For any answer of "Fail" above, describe in Section XV how and when these issues were or will be corrected. XV. COMMENTS S 4 HIGH LIQUID NOT WORKING - Repair and retest by others i i i GPH = Gallons Per Hour, Y = Yes, N = No, NA = Not Applicable, VPH = Vacuum/PressureMydrostatic, ID = Identification i